Antipsychotics prescribed for other indications

To support review of individuals prescribed antipsychotics. Antipsychotics are used in the management of mental health conditions, symptoms of stress and distress in dementia, and delirium in adults, with an increase in prescribing for non-severe mental illness.^244,245 People who receive antipsychotics commonly experience multimorbidity and polypharmacy,^246,247 therefore proactive routine medication reviews may enable appropriate deprescribing.

This hot topic discusses:

1. antipsychotic use in severe mental illness
2. antipsychotics prescribed for other indications

Antipsychotics in palliative care are out with the scope of this hot topic. Refer to Scottish Palliative Care Guidelines.¹⁵⁸

Antipsychotics may be prescribed without a clear indication for use or for indications not considered essential, these individuals should be reviewed to ensure prescribing remains appropriate. The majority (~60-70%) of antipsychotic prescribing is for non-severe mental illness.^244,246,257

Indications not considered essential include:

• symptoms of stress and distress in dementia (SSDD)
• delirium
• anxiety, insomnia and/ or psychomotor agitation
• depression without psychotic features
• borderline personality disorder²⁵⁸
• challenging behaviour in learning disabilities²⁵⁹

SSDD was previously referred to as behavioural and psychological symptoms of dementia (BPSD) based on psychiatric distress in dementia. The terminology in trials and the evidence base is BPSD.

Discuss and consider with the individual, next of kin or welfare guardian (dependent on individual capacity):

• potential factors contributing to symptoms, e.g. anticholinergic burden, infection, pain^133,260
• use of non-pharmacological interventions is advised, for example:
  • in SSDD: before antipsychotics are prescribed, non-pharmacological measures must be tried. See Alzheimer’s Society: non-drug approaches to changes in mood and behaviour²³⁹
  • in delirium: non-pharmacological measures must be tried before antipsychotics are prescribed, e.g. use of verbal and non-verbal de-escalation techniques²⁶⁰

If antipsychotics are prescribed:

• agree the therapeutic objectives, balancing benefits and risks of treatment
• discuss the evidence base of antipsychotic use
• consider existing medications, comorbidities, adverse effects and risk factors
• use the lowest effective dose for the shortest time-period²¹⁵
• follow local and national guidance for baseline and regular monitoring of the individual’s physical health, e.g. blood pressure and pulse, weight, HbA1c, lipids, prolactin and other blood tests.^180,215,248

Antipsychotics in symptoms of stress and distress in dementia and delirium

Please note that the table below may need to be scrolled horizontally or vertically in order to view all information, depending on your device.

Regular monitoring of efficacy and safety of treatment is needed e.g. for SSDD in care homes:

• assess the reduction in the number of stress and distress incidents per week or month
• obtain qualitative feedback from relatives and/or care staff on the individual

Seek specialist advice in

• severe mental illness
• individuals who have had repeated unsuccessful deprescribing attempts²⁶⁴

• older adults with dementia: increased risk of cerebrovascular adverse events and greater mortality²⁵⁴
• adults with pre-existing stroke risk factors254cardiometabolic risk: identify (using a suitable tool such as ASSIGN-2, QRisk-3, QDiabetes), monitor and manage modifiable risk factors²⁵⁴
• risk factors for venous thromboembolic events should be identified and prevented²⁵⁵
• follow local and national guidance for baseline and regular monitoring of the individual’s physical health, e.g. blood pressure and pulse, weight, HbA1c, lipids, prolactin and other blood tests^180,215,248

Reducing or stopping antipsychotic medications should be considered in individuals:

• with no valid indication²⁶⁵
• who experience clinically significant side effects²⁶⁵
• with poor adherence to oral treatment, consider alternative preparations if appropriate²⁶⁵
• who are not responsive to treatment after an adequate trial on optimal dose²⁶⁵

In addition, in SSDD (psychosis, agitation, persistent aggression):

• review at least every six weeks to check whether medication is still needed
• consider deprescribing within three months of initiation^133,266

Deprescribing

• Stop antipsychotic immediately if serious adverse effects occur
• See Maudsley Prescribing Guidelines for reduction or discontinuation regimen for antipsychotic drugs in SSDD¹⁸⁰
• Slower tapering may be required for those with severe SSDD or on long-term antipsychotics
• Regularly assess for symptom re-emergence after discontinuation
• Record reasons for continuing, stopping or reducing doses of medication
• Consider pausing planned reduction if there is a change in individual circumstances until situation settles, e.g. move of care setting, intercurrent illness, requirement for infection control isolation

Algorithm for antipsychotic deprescribing^{133,265,266,267}

(Click on image to enlarge)

Supporting people who do not or cannot reduce/stop

It is sometimes difficult to reduce or stop antipsychotics, and support is required.²⁶⁴ Ensure individual and/or carer understands the risks and benefits of treatment, and that these may change over time, therefore ensure regular review.

Specific areas/situations where medication may need to be introduced or increased

In individuals who experience recurrent or discontinuation/withdrawal symptoms, the previous lowest tolerated dose should be prescribed.²⁶¹

Does the person understand the outcomes of the review, including risk and benefits?

• Reducing/stopping antipsychotics should employ a person-centred and shared decision-making approach
• The individual is advised not to stop abruptly due to the risk of discontinuation/withdrawal symptoms
• Provide information on self-monitoring and what to do if symptoms re-occur

Is drug therapy tailored to the individual?

• The individual’s preferences, values and needs should be considered
• Ensure the individual is supported during a gradual reduction process, as this improves the acceptability
• Ensure the reduction is at the right time for the individual
• Understand past experiences of withdrawal

Agree the plan

• Offer a non-pharmacological management plan
• The reducing/stopping plan should be shared and agreed with the individual and/ or carers (written and/or verbal plan).

• self-management/support tools
• decision aids

NICE Decision Aid: Antipsychotic medicines for treating agitation, aggression and distress in people living with dementia

Healthcare Improvement Scotland: Delirium Toolkit

National Therapeutic Indicators (NTIs) use prescription data in specific areas to provide a measure of prescribing activity for comparison across NHS Boards, Health and Social Care Partnerships (HSCPs), GP clusters and GP practices.

NTIs are available to view online.

NTIs benchmark prescribing across set parameters and are presented in a variety of ways. Examining variation over time can indicate where improvements in prescribing can be made. The indicator detail provides further information and suggested actions.

Indicators for this hot topic include:

• Number of people aged 75 years and over prescribed an antipsychotic as a percentage of all people aged 75 years and over. See the chart below
• People receiving three or more of benzodiazepine/z-drug, opioid (including tramadol), gabapentinoid, antidepressant or antipsychotic (excluding depots)

Number of people aged 75 years and over prescribed an antipsychotic as a percentage of all people aged 75 years and over

(Click on image to enlarge)